In this physician's view, Medicare is the cause of the primary care crisis, and Medicare can provide the solution.

By Stephen Schimpff, M.D.

Primary care physicians have been marginalized by Medicare for decades with low reimbursement rates for routine office visits, which have led to the 15-20 minute office visit with 10-12 minutes of actual face time and a panel of patients that well exceeds 2000.

Is there a good solution to the Medicare cost and quality issues? Setting aside either the Democrats’ approach to basically enact price controls by ratcheting down reimbursements or the Republicans' plan to re-structure Medicare to a defined contribution plan, albeit not for ten years, are there approaches that could be instituted now that would have an immediate impact on improving quality of care and thereby reducing costs?

A 10-12 minute interaction means no time for the doctor to truly listen, no time to prevent, no time to coordinate and no time to just think. This has in turn meant that whenever a patient has a slightly more complex issue, one that is not easily recognized in a short time frame, the primary care physician is quick to refer to a specialist. It is this very act that dramatically drives up expenditures with added tests, imaging and procedures along with the specialist’s fees. Medicare has been exceptionally shortsighted in this regard and as a result is the prime culprit in the rapidly rising costs of care.

Further, this lack of time means that two critical quality care needs are left largely unattended: extensive preventive care and care coordination for the chronically ill. Recall that 85 percent of Medicare enrollees have at least one chronic illness and 50 percent have three or more. These are mostly the result of years of adverse behavior patterns, but it is never too late to begin preventive care, so time spent here is valuable for better health quality and ultimately reduced costs.

And those with a chronic illness need a coordinated care team. Every team needs a quarterback, and the primary care physician is the obvious choice. But Medicare does not reimburse for this critical function, which when done correctly means less reliance on specialists, tests, procedures and prescriptions. The result of this low reimbursement for routine visits and lack of reimbursement for either extensive preventive care or chronic care coordination over the years is a primary care physician shortage, physicians that don’t accept Medicare, and physicians that try to see 24 to 25 patients or more per day, each for 15 minutes despite the patient’s complex problem list. And this means less than stellar patient care in many instances.

The result is a real problem facing Medicare right now — the rapid loss of primary care physicians who no longer accept Medicare. In 2009, 3700 physicians opted out of Medicare; the number rose to 9500 in 2012, according to CMS in a Wall Street Journal article – this on top of the shortage of primary care physicians across the country, with no end in sight.

The ACA does include an extra 10 percent increase to primary care providers but this will probably be too little, too late. And if Congress ever implements the mandated 27 percent cut in reimbursement for physicians across the board (it probably never will but Congress refuses to clarify itself), then it is reasonable to expect a mass exodus of all physicians from accepting Medicare reimbursements, not just those in primary care.

What is the fix? As long as fee-for-service predominates the payment system, Medicare needs to increase its reimbursement of primary care physicians in a manner that ensures that they will spend more time with patients per visit. Time to listen, to prevent, to coordinate and to think. And in a capitated system, Medicare (or its agent) needs to pay enough per patient per month per year to ensure that no primary care doctor has more than a maximum of 1000 patients (even fewer if the practice is largely geriatric), so that there can be adequate time per patient encounter.